SF 2607

Introduction - 94th Legislature (2025 - 2026)

Posted on 07/09/2025 09:08 a.m.

A bill for an act
relating to human services; modifying applicability of prior authorization clinical
criteria changes and utilization review provisions; amending Minnesota Statutes
2024, sections 62M.17, subdivision 2; 256B.0625, subdivision 25c.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2024, section 62M.17, subdivision 2, is amended to read:

Subd. 2.

Effect of change in prior authorization clinical criteria.

(a) If, during a plan
year, new text begin or a calendar year for fee-for-service providers under chapters 256B and 256L, new text end a
utilization review organization changes coverage terms for a health care service or the
clinical criteria used to conduct prior authorizations for a health care service, the change in
coverage terms or change in clinical criteria shall not apply until the next plan year new text begin , or the
next calendar year for fee-for-service providers under chapters 256B and 256L, new text end for any
enrollee who received prior authorization for a health care service using the coverage terms
or clinical criteria in effect before the effective date of the change.

(b) Paragraph (a) does not apply if a utilization review organization changes coverage
terms for a drug or device that has been deemed unsafe by the United States Food and Drug
Administration (FDA); that has been withdrawn by either the FDA or the product
manufacturer; or when an independent source of research, clinical guidelines, or
evidence-based standards has issued drug- or device-specific warnings or recommended
changes in drug or device usage.

(c) Paragraph (a) does not apply if a utilization review organization changes coverage
terms for a service or the clinical criteria used to conduct prior authorizations for a service
when an independent source of research, clinical guidelines, or evidence-based standards
has recommended changes in usage of the service for reasons related to patient harm. This
paragraph expires December 31, 2025, for health benefit plans offered, sold, issued, or
renewed on or after that date.

(d) Effective January 1, 2026, and applicable to health benefit plans offered, sold, issued,
or renewed on or after that date, paragraph (a) does not apply if a utilization review
organization changes coverage terms for a service or the clinical criteria used to conduct
prior authorizations for a service when an independent source of research, clinical guidelines,
or evidence-based standards has recommended changes in usage of the service for reasons
related to previously unknown and imminent patient harm.

(e) Paragraph (a) does not apply if a utilization review organization removes a brand
name drug from its formulary or places a brand name drug in a benefit category that increases
the enrollee's cost, provided the utilization review organization (1) adds to its formulary a
generic or multisource brand name drug rated as therapeutically equivalent according to
the FDA Orange Book, or a biologic drug rated as interchangeable according to the FDA
Purple Book, at a lower cost to the enrollee, and (2) provides at least a 60-day notice to
prescribers, pharmacists, and affected enrollees.

Sec. 2.

Minnesota Statutes 2024, section 256B.0625, subdivision 25c, is amended to read:

Subd. 25c.

Applicability of utilization review provisions.

Effective January 1, 2026,
the following provisions of chapter 62M apply to the commissioner when delivering services
under chapters 256B and 256L: 62M.02, subdivisions 1 to 5, 7 to 12, 13, 14 to 18, and 21;
62M.04; 62M.05, subdivisions 1 to 4; 62M.06, subdivisions 1 to 3; 62M.07; 62M.072;
62M.09; 62M.10; 62M.12; new text begin and new text end 62M.17, subdivision 2 deleted text begin ; and 62M.18 deleted text end .